Form FC2 NM "Statement of Facts Supporting Eligibility for AFDC-Extended Foster Care (Efc)" - California

What Is Form FC2 NM?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FC2 NM by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form FC2 NM "Statement of Facts Supporting Eligibility for AFDC-Extended Foster Care (Efc)" - California

Download PDF

Fill PDF online

Rate (4.5 / 5) 68 votes
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR AFDC-EXTENDED FOSTER
ELIGIBILITY WORKER ONLY
CARE (EFC)
DATE:
I I
APPLICATION FOR RE-ENTRY
INSTRUCTIONS: Nonminors entering EFC after an absence from care shall complete in ink
I I
REDETERMINATION
all questions to the left of the heavy black line. The Nonminor completes the non-shaded
CASE NAME
sections of this form instead of the BCJA 2 or SAWS 2; the placement worker/county welfare
department is to complete the shaded portions.
CASE NUMBER
VERIFICATION
Completed by the Nonminor (NM)
1.
I I
I I
NAME OF NM
2.
Former Foster Care Status
MALE
FEMALE
3A
3.
PLACEMENT ADDRESS
.
PHONE
Termination of Prior Jurisdiction
4.
5.
CURRENT ADDRESS (IF DIFFERENT FROM PLACEMENT ADDRESS)
PHONE
6.
7.
BIRTH DATE
BIRTHPLACE
AGE
SOCIAL SECURITY NUMBER
I I
I I
8.
9.
YES
NO
SOCIAL SECURITY #
APPLIED FOR?
10.
I I
I I
11.
CITIZEN OF U.S.?
YES
NO
ALIEN STATUS:
CITIZENSHIP/ALIEN STATUS
I I
I I
12.
YES
NO
DO YOU HAVE MEDICAL INSURANCE?
IF YES, LIST POLICY NUMBER, COMPANY NAME, AND NAME OF POLICY:
I I
I I
13.
?
YES
NO
DO YOU HAVE REAL OR PERSONAL PROPERTY
IF YES, LIST PROPERTY TYPE (LAND, CASH, AUTO, MOTORCYCLE, LIFE INSURANCE, TRUST FUND, BANK ACCOUNT, BOND, ETC.) AND ITS VALUE:
NM’s Property ($10,000 Exclusion)
Property Verification
I I
I I
14..
YES
NO
DO YOU HAVE INCOME?
I I
I I
Received
Pending
IF YES, LIST AMOUNTS BELOW. IF APPLICATION PENDING, CHECK ASSOCIATED BOX.
Income Type
Amount
Pending
I I
SOCIAL SECURITY (SSA OR SSI/SSP) CIRCLE ONE
I I
CHILD SUPPORT
UNEMPLOYMENT BENEFITS
I I
PENSIONS
I I
DISABILITY (STATE WORKMAN’S COMPENSATION, ETC)
I I
IN-KIND INCOME (FREE RENT, UTILITIES, FOOD)
I I
SALARY/WAGES
I I
SCHOLARSHIP/GRANTS
I I
OTHER
I I
IF EARNED INCOME:
NAME OF EMPLOYER:
Income Verification:
ADDRESS:
I I
I I
Received
Pending
I I
Current TILP exempt earned income
WORK HOURS/MONTH:
FC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTED
PAGE 1 OF 2
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR AFDC-EXTENDED FOSTER
ELIGIBILITY WORKER ONLY
CARE (EFC)
DATE:
I I
APPLICATION FOR RE-ENTRY
INSTRUCTIONS: Nonminors entering EFC after an absence from care shall complete in ink
I I
REDETERMINATION
all questions to the left of the heavy black line. The Nonminor completes the non-shaded
CASE NAME
sections of this form instead of the BCJA 2 or SAWS 2; the placement worker/county welfare
department is to complete the shaded portions.
CASE NUMBER
VERIFICATION
Completed by the Nonminor (NM)
1.
I I
I I
NAME OF NM
2.
Former Foster Care Status
MALE
FEMALE
3A
3.
PLACEMENT ADDRESS
.
PHONE
Termination of Prior Jurisdiction
4.
5.
CURRENT ADDRESS (IF DIFFERENT FROM PLACEMENT ADDRESS)
PHONE
6.
7.
BIRTH DATE
BIRTHPLACE
AGE
SOCIAL SECURITY NUMBER
I I
I I
8.
9.
YES
NO
SOCIAL SECURITY #
APPLIED FOR?
10.
I I
I I
11.
CITIZEN OF U.S.?
YES
NO
ALIEN STATUS:
CITIZENSHIP/ALIEN STATUS
I I
I I
12.
YES
NO
DO YOU HAVE MEDICAL INSURANCE?
IF YES, LIST POLICY NUMBER, COMPANY NAME, AND NAME OF POLICY:
I I
I I
13.
?
YES
NO
DO YOU HAVE REAL OR PERSONAL PROPERTY
IF YES, LIST PROPERTY TYPE (LAND, CASH, AUTO, MOTORCYCLE, LIFE INSURANCE, TRUST FUND, BANK ACCOUNT, BOND, ETC.) AND ITS VALUE:
NM’s Property ($10,000 Exclusion)
Property Verification
I I
I I
14..
YES
NO
DO YOU HAVE INCOME?
I I
I I
Received
Pending
IF YES, LIST AMOUNTS BELOW. IF APPLICATION PENDING, CHECK ASSOCIATED BOX.
Income Type
Amount
Pending
I I
SOCIAL SECURITY (SSA OR SSI/SSP) CIRCLE ONE
I I
CHILD SUPPORT
UNEMPLOYMENT BENEFITS
I I
PENSIONS
I I
DISABILITY (STATE WORKMAN’S COMPENSATION, ETC)
I I
IN-KIND INCOME (FREE RENT, UTILITIES, FOOD)
I I
SALARY/WAGES
I I
SCHOLARSHIP/GRANTS
I I
OTHER
I I
IF EARNED INCOME:
NAME OF EMPLOYER:
Income Verification:
ADDRESS:
I I
I I
Received
Pending
I I
Current TILP exempt earned income
WORK HOURS/MONTH:
FC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTED
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ELIGIBILITY WORKER ONLY
TO BE COMPLETED BY PLACEMENT WORKER/COUNTY WELFARE DEPARTMENT STAFF
SOC 161
15A. Application: Did the NM sign a voluntary reentry agreement?
SOC 163
15B. Redetermination: Does the NM have a curernt Transitional Independent Living Plan?
I I
I I
YES
NO
16.
What is the authority for the NM’s out of home placement?
I I
Voluntary re-entry agreement (SOC 163)
Date:
I I
Mutual agreement (SOC 162)
Date:
I I
Court Order of Placement and Care Vested with Agency
Date:
Check box to indicate which court order finding was made and enter date of hearing/order.
Court Order Findings
Petition/Order
388 (e)
6 month status
12 month PP
Finding
Petition
review
hearing
COURT ORDER FINDINGS MADE?
Hearing
I I
I I
Finding a:
Yes
No
I I
I I
Finding b:
Yes
No
NA
NA
a).
Reentry and remaining in foster care in the NM’s
best interest
NA
b).
Reasonable efforts to finalize permanency
I I
ELIGIBLE FACILITIES
REQUIREMENTS MET
NM
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.
I I
SERVICES REQUIREMENTS
SIGNATURE OF NM (TO BE COMPLETED BY PLACEMENT WORKER/COUNTY WELFARE DEPARTMENT IF NM UNAVAILABLE OR UNABLE TO
MET
COMPLETE AND SIGN)
COUNTY WHERE SIGNED
DATE
PLACEMENT WORKER COUNTY OF JURISDICTION
ALL INFORMATION RECORDED ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
I I
NOT ELIGIBLE
I I
ELIGIBLE
NAME OF AGENCY
DATE
I I
FEDERAL
I I
NONFEDERAL
SIGNATURE OF ELIGIBILITY WORKER
DATE
I I
OTHER
SIGNATURE OF ELIGIBILITY WORKER SUPERVISOR
DATE
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-679) and the Information Practices Act of 1977 (Civil Code
Sections 1798, et. seq.), notice is hereby given for the request of personal information by this form. The
requested personal information is voluntary. The principal purpose of the voluntary information is to
facilitate the processing of this form. The failure to provide all or any part of the requested information
may delay processing of this form. No disclosure of personal information will be made unless
permissible under Article 6, Section 1798.17 of the IPA of 1977. Each individual has the right upon
request and proper identification, to inspect all personal information in any record maintained on the
individual by an identifying particular. Direct any inquiries on information maintenance to your IPA
Forms Officer.
FC 2 NM (2/12) REQUIRED FORM -- NO SUBSTITUTES PERMITTED
PAGE 2 OF 2
Page of 2